MEDICARE: NORTHSIDE PHARMACY GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PENDING	GA

General Provider Information

NPI Number	:	1871780270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE PHARMACY GROUP, INC.

Provider Business Mailing Address
First Line	:	2007 GILLIONVILLE RD
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-3139
Country	:	US
Telephone Number	:	229-436-2985
Fax Number	:	229-436-2987

Provider Business Practice Location Address
First Line	:	2007 GILLIONVILLE RD
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31707-3139
Country	:	US
Telephone Number	:	229-436-2985
Fax Number	:	229-436-2987

Authorized Official
Title or Position	:	VICE-PRESIDENT
Name	:	BEAL MARL HALBROOK
Credential	:	PHARM. D.
Telephone Number	:	229-436-2985

Provider Enumeration Date	:	09/29/2007
Last Update Date	:	06/20/2008

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